Neck of femur fractures in the elderly: Does every hour to surgery count?

doi:10.1016/j.injury.2017.03.007

Injury

Volume 48, Issue 6, June 2017, Pages 1155-1158

https://doi.org/10.1016/j.injury.2017.03.007 Get rights and content

Abstract

Objectives

To determine if early surgery before 12 h confers a survival or length of stay benefit for patients with neck of femur (NOF) fractures.

Design

Retrospective review of prospectively collected data.

Setting

District general hospital.

Patients

1913 patients aged over 60 admitted with a fractured NOF who underwent surgery between 2011 and 2015. Mean age was 83.9 years. 73.7% were female.

Intervention

Patients had surgery for fractured NOF with data collected on demographics, mortality and length of stay.

Main outcome measurements

Data collected included gender, age, ASA grade, fracture anatomy, surgery, time to surgery, days spent in acute hospital and rehabilitation settings and 30-day mortality. Statistical analysis was used to identify independent predictors of mortality and length of stay.

Results

30-day mortality was 6.1% and the mean hospitalisation time was 13 ± 11.3 days for the acute hospital and 20.2 ± 17.2 days for the trust. Operations were performed at a mean of 23.8 ± 14.8 h after presentation. Age, gender, ASA grade and type of fracture were independent predictors of either mortality or length of stay. Timing of surgery had an association with mortality but this only reached statistical significance at 24 h.

In line with previous studies we analysed time to surgery in 12 h blocks. We also used logistic regression, recognizing time as a continuous variable, which revealed that every hour of delay to surgery increased the mortality risk by 1.8%.

Conclusions

While every hour of delay increased mortality risk, the association with mortality only became statistically significant when delaying over 24 h. This supports a pragmatic approach, with surgery as soon as medically possible without a race to theatre.

Level of evidence

Level III retrospective cohort study.

Introduction

Hip fractures in the elderly are common and are increasing. It is estimated that worldwide hip fracture incidence will be 4.5 million by 2050 [1]. They account for the majority of fracture related healthcare costs and mortality in people over 50 [2].

Mortality and morbidity in hip fracture patients are multifactorial [3]. There is an accepted relationship between delay to surgery and increased mortality in patients with neck of femur (NOF) fracture [4], [5], [6]. However there is a lack of consensus on the optimum threshold for surgery.

Most studies mention a 48 h cut off [7], [8], [9]. Guidelines in the UK advise surgery before 36 h and in the USA before 48 h [10], [11]. Some delay has been seen as legitimate in order to allow medical optimization and presence of appropriately experienced surgeons and anaesthetists [11].

However, more recently there have been studies that have found mortality benefits from a much earlier surgical cut off of 12 h [12], [13].

The aim of this study was to determine if early surgery before 12 h conferred a survival or length of stay benefit. Other patient factors such as age, gender, ASA (American Society of Anesthesiologists) grade, fracture anatomy and type of operation were also analysed and corrected for to reduce confounding bias.

Section snippets

Methods

This was a retrospective review of data that was prospectively collected on patients admitted to Ashford and St Peter’s Hospital NHS Trust between 2011 and 2015 following a NOF fracture. NOF was defined as a fracture from the head of the femur to 5 cm below the lesser trochanter. Patients under 60 years of age were excluded from the study.

Data was gathered on demographics, fracture anatomy, operations, ASA grade and hospitalisation for all patients. Time to surgery was defined as time from

Descriptives

A total of 1913 patients, aged 83.9 years ± 8.3 (range 60–105 years) were included in the study. The majority of the patients were female (73.7%). The most frequent type of fracture was the intra-capsular neck of femur fracture (49.7%) and the most frequent operation was the hip hemiarthroplasty (44.5%). Thirty days mortality was 6.1% and the mean hospitalisation time was 13 ± 11.3 days for the acute hospital and 20.2 ± 17.2 days for the Trust. Table 1 summarises the demographic, injury and operation

Discussion

In the effort to improve outcomes in the care of elderly patients with neck of femur fractures, there has been a search for factors that can be modified to confer benefit, such as time to surgery. Previous research and guidelines have defined early surgery for NOF fractures as within 24–48 h [5], [6], [7], [8], [9], [10], [11], [14]. Moja et al. have carried out a systematic review which confirmed earlier findings by Simunovic et al. that surgery conducted within 24–48 h was associated with lower

Conclusion

This study found that operating within 12 h did not have a significant effect on mortality. However delaying beyond 24 h did have an adverse effect and the risk of mortality increased by 1.8% for every hour of delay. This supports a safe and pragmatic approach with surgery as soon as medically possible without a race to theatre.

Conflict of interest

None declared.

Funding

None.

References (21)

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Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey
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El Apgar quirúrgico (AQ) es una puntuación evaluadora del riesgo perioperatorio, que evalúa intraoperatoriamente la frecuencia cardiaca mínima, la presión arterial media mínima y la pérdida de sangre estimada. Aunque ha sido validado en múltiples campos quirúrgicos, el AQ sigue siendo controvertido en el campo traumatológico. El objetivo principal de este estudio fue investigar si AQ guarda relación con la incidencia de complicaciones durante los primeros 30 días tras la cirugía de fractura femoral proximal.
Estudio retrospectivo que incluyó todos los pacientes consecutivos sometidos a cirugía de fractura femoral proximal entre enero y julio de 2019. Se excluyó a los pacientes que carecieran de información sobre el AQ. Se dividió a los pacientes en dos grupos, sobre la base de la incidencia de complicaciones durante los primeros 30 días postoperatorios y el cálculo de su AQ. Se utilizaron curvas ROC (característica operativa del receptor) para evaluar el modelo predictivo de complicaciones.
El 44% (n = 76) de los 181 pacientes incluidos en el estudio desarrollaron complicaciones durante los primeros 30 días postoperatorios. Ocho pacientes (4,4%) fallecieron durante dicho periodo. La edad media de los pacientes fue de 79 años, y el 30,9% (n = 56) fueron varones. La insuficiencia cardiaca (IC), el uso de marcapasos, la enfermedad renal crónica, la enfermedad pulmonar obstructiva crónica y la demencia estuvieron significativamente asociadas a la morbilidad postoperatoria. No existió correlación significativa entre AQ y la incidencia de complicaciones durante los primeros 30 días postoperatorios. El ABC de AQ como modelo predictivo de complicaciones postoperatorias tras la cirugía de fractura femoral proximal fue de 0,522, lo cual es insuficiente para poder considerarse un modelo predictivo aceptado.
Sobre la base de este estudio, concluimos que AQ no es predictivo del desarrollo de complicaciones en los primeros 30 días postoperatorios en pacientes sometidos a cirugía de fractura femoral proximal. Sin embargo, se han identificado otros factores clínicos asociados con la morbilidad postoperatoria. En el futuro, los estudios de tipo prospectivo con muestras de mayor tamaño podrán esclarecer de mejor manera el rol de AQ en este contexto.
The surgical Apgar score (SAS) is a perioperative risk evaluation score, which considers intraoperative minimum heart rate, minimum mean arterial pressure and estimated blood loss. Although validated in multiple surgical fields, SAS remains quite controversial in the orthopedic one. The main purpose of this study was to investigate if SAS relates with the occurrence of complications during the first 30-days after proximal femoral fracture surgery.
Retrospective study including all consecutive patients submitted to proximal femoral fracture surgery between January and July 2019. Patients with no information about SAS were excluded. Patients were divided in two groups, based on the occurrence of complications during the first 30 post-operative days and their SAS calculated. Receiver operating characteristic (ROC) curves were used to assess SAS power as a predictive model of complications.
Forty-two percent (n = 76) of the 181 patients included in the study developed complications during the first 30 postoperative days. Eight patients (4,4%) died during that period. The patient's mean age was 79 years and 30,9% (n = 56) were men. Heart failure, pacemaker use, chronic kidney disease, chronic obstructive pulmonary disease and dementia were significantly associated with post-operative morbidity. There was no significant correlation between SAS and the occurrence of complications during the first 30 postoperative days. The AUC of SAS as a predictive model for postoperative complications after proximal femoral fracture surgery was 0,522, being insufficient to be considered an accepted model of prediction.
Based on this study, we conclude that SAS is not predictive of the development of complications in the first 30 post-operative days in patients submitted to proximal femoral fracture surgery. However, other clinical factors have been identified as associated with postoperative morbidity. In the future, prospective-based studies with higher samples may better clarify the role of SAS in this context.
Elbow to digit measurements as a preoperative adjunct tool to aid intramedullary femoral nail selection – the rule of thumb
2023, Injury
Intramedullary femoral nails are measured intraoperatively using fluoroscopy. This study aims to investigate whether distance from the olecranon to fingertips can be used to estimate nail length preoperatively by evaluating agreement of the two measurements. Such preoperative measurements may provide a likely range of nails needed for theatre and serve as an adjunct to intraoperative measurements.
In 70 patients, long leg radiographs were used to make linear measurements from the piriformis fossa and greater trochanter to the distal physeal scar of the femur. These were compared to measurements from the olecranon to the tip of each digit and Bland-Altman agreement analysis was performed. Train and Trial groups were formed to develop models for estimation and to then test their accuracy.
Bland-Altman analysis revealed a fixed bias, indicative of average difference between measurements, of 1.4 cm when comparing the elbow-thumb length to maximum femoral nail length for piriformis fossa entry and 3.5 cm using greater trochanter entry, informing the “rule of thumb”. Elbow-thumb length plus 1.4 cm or 3.5 cm predicts nail length to a range of ± one nail increment. The rule can be used to preoperatively predict a range of three nails from which there is a 94–97% likelihood the appropriate intramedullary nail would be selected.
The “rule of thumb” may serve as a simple to use tool for preoperative planning and a technical check to assess the “reasonableness” of intraoperative measurements before implantation of the device. It has the potential to reduce operating time and nail wastage.
Validation and algorithmic audit of a deep learning system for the detection of proximal femoral fractures in patients in the emergency department: a diagnostic accuracy study
2022, The Lancet Digital Health
Citation Excerpt :
Of those patients undergoing additional imaging, only around a third are ultimately ever diagnosed with a fracture.3,4 Not only does further imaging increase the diagnostic costs, the burden on doctors and patients, and resource use, but so-called occult fractures could also lead to delayed diagnoses and concomitant worse patient outcomes, including increased mortality rate,5,6 length of hospitalisation,7 and cost of care.8 Improved diagnostic accuracy at first clinical presentation could plausibly reduce both harms and costs.
Proximal femoral fractures are an important clinical and public health issue associated with substantial morbidity and early mortality. Artificial intelligence might offer improved diagnostic accuracy for these fractures, but typical approaches to testing of artificial intelligence models can underestimate the risks of artificial intelligence-based diagnostic systems.
We present a preclinical evaluation of a deep learning model intended to detect proximal femoral fractures in frontal x-ray films in emergency department patients, trained on films from the Royal Adelaide Hospital (Adelaide, SA, Australia). This evaluation included a reader study comparing the performance of the model against five radiologists (three musculoskeletal specialists and two general radiologists) on a dataset of 200 fracture cases and 200 non-fractures (also from the Royal Adelaide Hospital), an external validation study using a dataset obtained from Stanford University Medical Center, CA, USA, and an algorithmic audit to detect any unusual or unexpected model behaviour.
In the reader study, the area under the receiver operating characteristic curve (AUC) for the performance of the deep learning model was 0·994 (95% CI 0·988–0·999) compared with an AUC of 0·969 (0·960–0·978) for the five radiologists. This strong model performance was maintained on external validation, with an AUC of 0·980 (0·931–1·000). However, the preclinical evaluation identified barriers to safe deployment, including a substantial shift in the model operating point on external validation and an increased error rate on cases with abnormal bones (eg, Paget's disease).
The model outperformed the radiologists tested and maintained performance on external validation, but showed several unexpected limitations during further testing. Thorough preclinical evaluation of artificial intelligence models, including algorithmic auditing, can reveal unexpected and potentially harmful behaviour even in high-performance artificial intelligence systems, which can inform future clinical testing and deployment decisions.
None.
CCD angle & hip fractures – Predictor of fracture symmetry?
2021, Journal of Orthopaedics
Hip fracture caused by fall is a common injury of the elderly. The risk of sustaining a contralateral hip fracture has been reported to be 5–10%. Aging society heightens the need of efficient prevention tools. To be able to cope with this demand, understanding of biomechanics of hip fractures are mandatory. Previous studies suggest that geometry of the proximal femur could play an important role for fracture probability and fracture type. Thus, analysis of hip geometry could play an important role in the prediction and prevention of bilateral hip fractures. Aim of this study was to elucidate the influence of caput collum diaphyseal angle on the fracture type of proximal femur.
In a retrospective analysis, data of patients with an acute hip fracture who underwent surgical treatment within five years were included. Data was separated into two groups: (I) intra capsular femur fracture (femoral neck fractures) and (II) extra capsular femur fracture (inter- and subtrochanteric femur fractures). Occurrence of a bilateral fracture, age, gender, weight, height and caput collum diaphyseal angle (standardized measurement of the opposite joint on preoperative digital x-rays) of each group were further analyzed.
Data of 448 patients were included ((I): 250 vs. (II): 198 patients). Group (I) showed a significant higher mean caput collum diaphyseal angle of 133.9 ± 7.0° (mean ± standard deviation) compared to group (II) with 127.6 ± 6.1° (F (1, 451) = 106.5, p = 0.00). In group (I) 0 patients had a caput collum diaphyseal angle <120° (varus), 214 patients (86%) 120°–140° and 35 patients (14%) angle>140° (valgus). In contrast, in group (II) 21 patients (10%) had a caput collum diaphyseal angle <120° (varus), 175 patients (86%) 120°–140° and 7 patients (4%) >140° (valgus). 52 patients had a bilateral hip fracture. 36 patients (69%) sustained a bilateral hip fracture of the same fracture type.
Patients with an intra capsular proximal femur fracture showed a significantly higher caput collum diaphyseal angle compared to patients with an extra capsular proximal femur fracture. Moreover, intra capsular femur fractures are correlated with an indifferent (120–140°) or valgus (>140°) femoral neck configuration. Extra capsular femur fractures correlate with an indifferent (120–140°) or varian femoral neck configuration (<120°). The results support the assumption that the caput collum diaphyseal angle has an influence on fracture type of the proximal femur. This could possibly be a predictor for the fracture type of the contralateral hip (second fracture). Based on this, present data may benefit prosthetists in developing new and more efficient hip protectors.
Level III. Retrospective comparative study.
Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: A retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®
2021, Injury
Time-to-surgery in geriatric hip fractures remains of interest. The majority of the literature reports a significantly decreased mortality rate after early surgery. Nevertheless, there are some studies presenting no effect of time-to-surgery on mortality. The body of literature addressing the effect of an orthogeriatric co-management is growing. Here we investigate the effect of time-to-surgery on in-house mortality in a group of patients treated under the best possible conditions in certified orthogeriatric treatment units.
We conducted a retrospective cohort registry analysis from prospectively collected data of the AltersTraumaRegister DGU®. Data were analyzed univariably, and the association of early surgery with in-house mortality was assessed with multivariable logistic regression while controlling for specified patient characteristics. Additionally, propensity score matching for time-to-surgery was applied to examine its effect on the in-house mortality rate.
A total of 15,099 patients met the inclusion criteria. The median age was 85 years (IQR 80–89), and 72.1% were female. The overall in-house mortality rate was 5.5%. Most (71.2%) of the patients were treated within 24 h, and 91.6% within 48 h. Neither the multivariable logistic regression model nor the propensity score matching indicated that early surgery was associated with a decreased mortality rate. The most important indicators for mortality were ASA ≥ 3 [Odds ratio (OR) 3.4, 95% confidence interval (CI) 2.35–5.11], fracture event during inpatient stay (OR 2.6, 95% CI 1.48–4.3), ISAR ≥ 2 (OR 1.88, 95% CI 1.33–2.76), and male gender (OR 1.71, 95% CI 1.39–2.09).
Our results suggest that for those patients, who were treated in an orthogeriatric co-management under the best possible conditions, there are no significant differences regarding in-house mortality rate between the time-to-surgery intervals of 24 and 48 h or slightly above. This and the comparatively small number of patients who underwent surgery after 24 h show that an extension of the pre-surgery interval, justified by an orthogeriatric treatment team, will not be detrimental to the affected patients.
Mortality and its risk factors in nonagenarians after hip fractures
2019, Journal of Orthopaedic Science
Citation Excerpt :
Time interval from trauma to operation as risk factor of mortality in this study might be an unusual finding. However, previous studies have persistently reported that time interval from trauma to operation is a major concern for patients after hip fracture [9,24–27]. Cha et al. [28] have assessed causal factors for delayed surgery that affect differences in mortality and found that drugs hold (aspirin, antiplatelet, warfarin) and patient's medical condition requiring surgical delay are patient factors that are significantly associated with death after hip fracture.
The purpose of this study was to assess mortality with a minimum of 2-year follow-up, related risk factors for mortality, and functional outcomes after surgical interventions in nonagenarian patients with hip fractures at the latest follow up.
Between June 2003 and November 2015, 260 nonagenarians (271 hips) with femoral neck and intertrochanteric fractures were included in this retrospective study. Cumulative mortality using the Kaplan-Meier method and risk factors for mortality using Cox proportional-hazards regression model were estimated. As functional outcome, ambulatory ability was assessed before injury and at the latest follow-up.
Six-teen patients (16 hips) were lost to follow-up. The mean age at the time of surgery was 92.2 years (range 90–108 years). Mortality rates were 23.4% (57 of 244 patients) at 1 year and 40.6% (99 of 244 patients) at 2 years. Both genders had elevated standardized mortality ratio at 2-year post-fracture compared to that a 1-year post fracture. Multivariate analysis showed that American Society of Anesthesiologists (OR, 1.371; 95% CI, 1.021–1.843; P = 0.036) and time interval from trauma to operation (OR, 1.043; 95% CI, 1.002–1.086; P = 0.039) were significantly associated with risk of mortality. Of 58 patients alive, 13 patients (22.4%) had the same ambulatory ability before and after injury.
This study demonstrates that mortality is higher in nonagenarians with hip fracture. Risk factors for mortality in nonagenarians with hip fracture are American Society of Anesthesiologists and time interval from trauma to operation. And, nonagenarians with hip fractures have lower rate of maintaining pre-injury ambulatory ability.

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Neck of femur fractures in the elderly: Does every hour to surgery count?

Abstract

Objectives

Design

Setting

Patients

Intervention

Main outcome measurements

Results

Conclusions

Level of evidence

Introduction

Section snippets

Methods

Descriptives

Discussion

Conclusion

Conflict of interest

Funding

Injury

J Orthop Sci

Injury

World-wide projections for hip fracture

Osteoporos Int

A systematic review of hip fracture incidence and probability of fracture worldwide

Osteoporos Int

Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the Scottish hip fracture audit

J Bone Joint Surgery Br

Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients

PLoS One

Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey

Int J Qual Heal Care

Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis

CMAJ

The effect of early surgery after hip fracture on 1-year mortality

BMC Geriatr